Open University Editorial Team

This is the third of six related articles, commencing with a piece by Professor Marsland in MSN Volume 14, Issue 2 in April 1989, and concluding with his report in MSN Volume 19, Issue 1 in December 1993, which are published here, together, for the first time.

Reform of Reaction in Health Care?Professor David MarslandWest London Institute, UK

Originally published in MSN Volume 15, Issue 1, December 1989

Parliament and the people are debating the Government’s proposed reforms of health care, so why shouldn’t medical sociologists join in? I was delighted, therefore, to read the response to my own analysis (Medical Sociology News, April) by Gareth Williams and Jonathan Gabe in the August issue. Before the reforms are enacted and the practical tasks of implementation are entered on constructively by all concerned, I have one last opportunity, for which I am grateful, to continue the debate.

My critics raised many interesting and important questions which will require more space for adequate response than I have here. I focus, therefore – leaving other more particular issues to be addressed in other arenas – on the two fundamental criticisms they deployed. These concern, first my alleged naivety about the concepts of “efficiency, consumer preference and value for money”, and second, the methodological role of values in social analysis.

Service for whom?

It seems to me wonderfully ironic that I should be accused of “taking concepts at face value” by critics who – in defending the status quo of an unreformed National Health Service – demonstrate their own willingness to take the thoroughly elastic concept of “service” entirely at face value. After forty years of social and medical change, the necessity of reform in British health care is now widely acknowledged. Admission that the hopeful promises of those who legislated the NHS have been less than wholly fulfilled implies no reneging on principled commitment to high quality health care for all. All that is entailed by acknowledgement of the necessity for reform is an honest, open-minded attempt at improving service quality, at turning the failed ideal of service into a reality.

In this attempt, the concepts of efficiency, value for money and consumer preferences are indispensable instruments of analysis. Despite Williams’ and Gabe’s strictures, each of these three concepts is clear, operational and practical. They provide bench-marks which can be applied coherently to any and all of the multifarious policies, programmes and procedures which comprise the health care system. If we measure the NHS, rigorously and across the board, in terms of efficiency, value for money and consumer satisfaction, we shall be on our way towards ensuring delivery of quality health care and genuine service throughout Britain.

Hidden agendas

While I am grateful to be spared “castigation” (Williams and Gabe, page 10) for my values – which are not dissimilar, as it happens, from those of rather large numbers of my fellow citizens – I was surprised that my critics should suggest that I need to be more open and explicit about them. I would have thought my scepticism about socialist and other collectivist principles and my resistance to sociological bias against markets, business, freedom and individualism had been set out thoroughly and explicitly in all my recent published work (please see references for examples).

My reading of British medical sociology (including Medical Sociology News) and the sociology of health more broadly suggests that the boot is on the other foot. If only medical sociologists had admitted explicitly in their relation to their analyses of the NHS, the medical profession, health inequalities and all the rest, the extent of their own commitments to socialism, collective provision, centralised planning and union power! If only student readers of our text books had been made aware of the role of authorially hidden agendas in the elegant marshalling of arguments, and of unexplicated values in the judicious selection of evidence!

What is essential, surely, is that sociological analysis of current health care reforms should be explicit, and reflexive, about a range of values – with objectivity, validity and practical relevance being pursued through wide-ranging debate and competitive testing of a variety of perspectives. The range of value-perspectives brought to bear in medical sociology in recent years, and in analysis of the current NHS reforms specifically, seems to me to have been clearly too narrow. Those who support NHS reform have no need to apologise for attempting to widen it just a little.

Protesting too much

It seems to me that over the intervening months, Chris Ham’s recommendation to “those on the left” (which I referred to in my earlier paper) of a “discriminating response” and his advice that “Outright rejection of the White Paper would be both wrong and a missed opportunity” have been sadly ignored. There is widespread conviction that the millions of pounds spent by the BMA on doctrinaire resistance to reform of the NHS have been mis-spent and counter-productive.

Reform of the NHS is essential. Our elected Government has brought forward its reform proposals for consideration in all the relevant arenas and made significant adjustments and concessions, given Parliamentary approval, the whole reform package will be implemented. If resistance persists, it will be justifiably interpreted as a product of dogmatic opposition to the whole idea of innovation and reform in health care. In a word – reaction.